Healthcare Provider Details

I. General information

NPI: 1659021996
Provider Name (Legal Business Name): MARISSA JEPSEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 09/21/2023
Certification Date: 01/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1512 DALY RD
WHEATON IL
60187-3310
US

IV. Provider business mailing address

40W927 IL ROUTE 64
ST CHARLES IL
60175-5314
US

V. Phone/Fax

Practice location:
  • Phone: 310-993-5230
  • Fax:
Mailing address:
  • Phone: 310-993-5230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number107341
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: